25 Jul 2025 Jordan Michael BABB · Prevention of Future Deaths report Milton Keynes
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Concerns raised 5 Lack of formal thresholds or protocols for urgent escalation of abnormal observations View source Lack of a specific protocol or decision-support mechanism for recognition and escalation of life-threatening conditions View source Failure to apply an evidence-based pulmonary embolism diagnostic pathway View source Lack of clarity or training on the scope and limitations of clinical decision tools View source Failure to use or document structured pulmonary embolism risk assessments View source See 2 more concerns
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Jordan Michael BABB · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jordan Michael BABB had chest pain and attended an urgent care centre on 13 September 2024, where he was assessed and discharged without investigation for a possible pulmonary embolism. He collapsed on 16 September 2024 and died of a pulmonary embolism. Concerns included failure to escalate abnormal observations, lack of a structured pulmonary embolism risk assessment, unclear use of clinical decision tools, and a risk of similar failings recurring.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Milton Keynes Urgent Care Services CIC; that does not assign responsibility.
PFD Monitor interpretation Lack of formal thresholds or protocols for urgent escalation of abnormal observations
Wider context from the report “1. Failure to Escalate Abnormal Observations
Despite the patient presenting with a significantly elevated heart rate, high respiratory rate, and reduced oxygen saturations — all indicative of physiological instability — there was no escalation to secondary care or referral to the emergency department. There appears to have been no formal threshold or protocol in place to ensure that abnormal observations of this nature trigger an urgent clinical response.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Milton Keynes Urgent Care Services CIC; that does not assign responsibility.
PFD Monitor interpretation Lack of a specific protocol or decision-support mechanism for recognition and escalation of life-threatening conditions
Wider context from the report “4. Risk of Repetition in Similar Settings
The inquest heard no evidence that the walk-in centre has a specific protocol or decision-support mechanism in place for the recognition and escalation of potentially life-threatening conditions such as pulmonary embolism. There is a risk that similar failings could occur in future, particularly where patients present with non-specific symptoms and abnormal vital signs.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Milton Keynes Urgent Care Services CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to apply an evidence-based pulmonary embolism diagnostic pathway
Wider context from the report “2. Lack of Structured Risk Assessment for Pulmonary Embolism
Although pulmonary embolism was a relevant clinical possibility, no structured risk assessment tool (such as the Wells score) was used or documented, and there was no attempt to apply an evidence-based diagnostic pathway as recommended by NICE guidance (NG158).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Milton Keynes Urgent Care Services CIC; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity or training on the scope and limitations of clinical decision tools
Wider context from the report “3. Unclear Use or Misunderstanding of Clinical Decision Tools
Evidence suggested uncertainty about the appropriate use of the Pulmonary Embolism Rule-out Criteria (PERC) in primary care settings, with potential misapplication outside of the specific context recommended by NICE (i.e., in low-risk patients only and following validated pre-test probability assessment). There appears to be a lack of clarity or training regarding the scope and limitations of such tools in the primary care context.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Milton Keynes Urgent Care Services CIC; that does not assign responsibility.
PFD Monitor interpretation Failure to use or document structured pulmonary embolism risk assessments
Wider context from the report “2. Lack of Structured Risk Assessment for Pulmonary Embolism
Although pulmonary embolism was a relevant clinical possibility, no structured risk assessment tool (such as the Wells score) was used or documented , and there was no attempt to apply an evidence-based diagnostic pathway as recommended by NICE guidance (NG158).
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations